Failures in a dementia patient’s care meant her final wish to die in her own bed surrounded by family was ignored, according to a damning report published today.

Failures in a dementia patient’s care meant her final wish to die in her own bed surrounded by family was ignored, according to a damning report published today.

The women’s daughter has described the circumstances surrounding her mother’s death as a “complete circus”, and says she missed out on spending precious time with her dying mother as a result of a care home’s errors.

A scathing report by the Public Services Ombudsman for Wales also revealed records showed the care home resident had only been bathed 11 times in nine months, and she had regularly been fed met despite being a vegetarian.

The woman, named only as Mrs X in the report, was a resident from April 2009 until her death in January 2010 at a Monmouthshire care home run by Aneurin Bevan Local Health Board, which specialised in the care of dementia patients.

Among the examples of poor care given to Mrs X – whose care plan showed she was a vegetarian who did not eat pasta, fish and curry – weekly diet sheets often referred to meat, spaghetti and curry with just one reference to the vegetarian alternative.

During her nine months at the care home, Mrs X also sustained a number of injuries but there was no evidence of lessons learned or that information about these was communicated to her daughter, identified only as Ms A in the report.

There was also no record of Mrs X’s end of life care wishes documented in the care plan or in Mrs X’s care home record.

In January 2010, Mrs X complained about chest problems and was set to see a GP the following morning.

Staff were due to check on her every half an hour overnight but there was only one record of a full observation taking place.

The following day, Mrs X’s condition deteriorated and she was referred to hospital. Ms A told staff her mother’s end of life plan had been to remain at the care home, but as there was no record of this, she was told by staff they could be liable for withholding treatment.

Doctors said Mrs X could be transferred back to the care home, but the manager said that this would not be possible because the district nurse had not been trained to administer the required treatments. Mrs X died at the hospital on January 12, 2010.

Ms A described the circumstances surrounding her mother’s final days as “deplorable”, “unforgivable” and a “complete circus”.

She said the confusion and uncertainty of whether Mrs X could be returned to the care home for palliative care resulted in her missing out on spending quality time with her mother in her final hours

Ombudsman Peter Tyndall said: “In the absence of alternative evidence I must express my concern that when addressing Mrs X’s nutritional, hygiene and safety needs, her care plan was ignored and Mrs X’s wellbeing and choice were disregarded.

“These failings had a detrimental effect on the fundamental aspects of Mrs X’s care and dignity.

“Ms A said that Mrs X had expressed a wish to die in her own bed with familiar surroundings and the people she cared for close by, and not be admitted to hospital.

“However Mrs X’s end of life care wishes were not documented. This a serious failing. Had the appropriate documentation been available Mrs X’s end of life wishes could have been granted.”

The Ombudsman also upheld a further complaint by Ms A about Care and Social Services Inspectorate Wales’ investigation of her concerns and recommended Ms A should be paid £250 by CSSIW and £500 by the Health Board.

He also made a number of recommendations including a review of policies and procedures for contracted out care.

Dr Andrew Goodall, chief executive of Aneurin Bevan Health Board, said: “Aneurin Bevan Health Board accepts the findings of the Ombudsman and would wish to offer its sincere apologies to the family for the failings identified within the report.

"The Health Board is aware that some of the matters in the report relate to a period up to and including October 2009, prior to the establishment of Aneurin Bevan Health Board. Soon after its establishment, the Health Board recognised the issues covered in the report and has responded to these through changes to our Policies and Procedures and our general approach as an organisation.

"The Health Board is committed to implementing the Ombudsman's recommendations to continue to further improve the care provided to residents in care homes in the future, and as Chief Executive I have met with the Ombudsman to discuss this specific case and the Health Board’s response to the report’s recommendations."

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